Joint Dementia Strategy 2019–24 · 2019. 9. 3. · • Improving access to palliative care...

Joint Dementia Strategy 2019–24

Improving the lives of people affected by dementia in the city of Wolverhampton

Appendix 1

CouncillorLinda Leach Cabinet Member for AdultsCity of Wolverhampton Council

David Watts Director of Adult ServicesCity of Wolverhampton Council

Steven MarshallDirector of Strategy and TransformationWolverhampton Clinical Commissioning Group

Wolverhampton Joint Dementia Strategy 2019-24

Executive Summary

It can affect any one at any time, and has a major impact on thequality of life of those living with the condition. It can also havea physical, psychological, social and economic impact on theirfamilies and carers too.

The Wolverhampton Dementia Action Alliance is determined todo all it can to support people living with dementia, and theirfamilies and carers. We are delighted that Wolverhampton hasbeen recognised as a Dementia Friendly City by the Alzheimer's Society, in recognition of the efforts that we - as acommunity - are making to improve services and to makeWolverhampton as friendly and welcoming as possible topeople living with dementia.

But there is much more we can and will do - and the Joint Dementia Strategy 2019–2024, an overarching document that incorporates the City of Wolverhampton Council andWolverhampton Clinical Commissioning Group’s commissioningintentions, will help us do this.

The strategy has been produced by a multi-agency workgroupincluding representation from the voluntary and communitysector as well as people with experience of dementia, boththose living with the condition and their families and carers.

It seeks to develop proactive services and ensure good qualitycare and support. It includes not just commissioned services tosupport people with a dementia diagnosis, but wider publicservices and workstreams to prevent dementia risk factors andpromote community asset-based services which will helppeople affected by dementia to live well in their community.

Ultimately, it will enable joint working across the voluntary,community, health and social care sectors, and aims to supportpeople living with dementia and their families and carers to havethe best possible life.

3

Dementia is a debilitating illness which is estimated to affect more than3,000 people in Wolverhampton - with that number expected to rise by over 50% by 2035.


Introduction

Dementia is one of the biggest challenges facing the nation today.

Some 650,000 people inEngland are believed to be living with dementia, including3,100 people in the city ofWolverhampton, withsomebody diagnosed with the condition every fourseconds worldwide.

Dementia is an umbrella term used to describe manydifferent types of dementia, particularly Alzheimer’sDisease, Vascular Dementia and Dementia with Lewybodies.

It can affect anyone and causes a decline in aperson’s cognitive (intellectual) abilities, affectingtheir memory, language, understanding, reasoning,problem solving and concentration, but eachperson’s dementia is unique and so affects their livesin very different ways.

Cases of dementia increase with age, and as lifeexpectancy increases, more and more people will beaffected. Currently, one in 50 people between theages of 65 and 70 have a form of dementia,compared to one in five over the age of 80. Around42,000 people under 65 are living with dementia andthis number is increasing.

Diagnosis is often made at a later stage of the illnessand this can affect the person’s ability to makechoices and decisions.

Of course, dementia does not just have adevastating effect on the individual, but also theirfamilies and friends. An estimated 21 million peopleknow a close friend or family member with dementia– that’s nearly half of the population, and it’simportant that they get the help and support theyneed to carry out their caring role.

Life should not stop because of dementia. Peoplewith dementia and their family and carers may needsupport to enable them to carry out activities andengage in relationships in a positive way, so thatthey can continue to lead a full and active life.

4Source: Alzheimer’s Society, Dementia UK, Fingertips PHE


The City of Wolverhampton’s Joint Dementia Strategy

The City of Wolverhampton Dementia ActionAlliance were proud to be awarded DementiaFriendly Community of the Year 2018. Already agreat deal of good work has taken place locallyto improve the lives of people with dementia andtheir families.

The City of Wolverhampton’s previous strategy wasdeveloped in 2015 by a multi-agency partnershipwith representation from the City of WolverhamptonCouncil, Wolverhampton Clinical CommissioningGroup, Royal Wolverhampton NHS Trust and BlackCountry Partnership Foundation Trust. Businesses,organisations, community groups and individualsalso came together through WolverhamptonDementia Action Alliance to develop this strategy for people affected by dementia in the city of Wolverhampton.

Reflecting both the local and national vision fortransforming dementia care and support, thestrategy seeks to develop proactive services andensure good quality care and support that bestmeets the needs of people living with dementia, their families and carers. It follows a person-centredapproach, putting the service user at the heart of thedecision-making process. The Strategy is alignedwith NICE Quality statements and was developed inline with Living well with dementia 2012 and PrimeMinisters Challenge on Dementia.

It highlights several key areas and actions, and animplementation plan to ensure a range ofimprovements are delivered.

Since 2015 there has been significant progress indeveloping and delivering support to people affectedby Dementia, including families and carers.

Due to the consultation and partnership approach todeveloping this updated Strategy, the coreaspirations remain unchanged. The way in which wedesign, develop and deliver support is changing dueto many factors, including the increasing populationand the increasing number of people beingdiagnosed with dementia in a climate of greatlyreduced finance and resources.

This update is therefore an opportunity to:

• Align our strategic approach with national policyand relevant local delivery models

• Review the aspirations of the Strategy

• Work with partners, service users and carers toset new actions to continue delivering outcomesfor people affected by dementia in the city ofWolverhampton.

• Drive new ways of working that will improveoutcomes and the support available

• Promote prevention messages and healthylifestyles especially to key age groups and Blackand Minority Ethnic communities in line with thefindings from Dementia UK, who highlighted intheir recent study key groups of people whoseunderstanding of dementia is lower, includingthose from black, Asian and minority ethnicbackgrounds, and adults under 24 and over 65.

• Reflect a stronger offer of support throughstrengthening partnerships with health, socialcare and community organisations

5


Joint Dementia Strategy Headlines

• Making the city of Wolverhampton a DementiaFriendly City, in which people with dementia andtheir carers feel confident to participate ineveryday life and can live well and independentlyfor as long as possible.

• Developing dementia awareness programmesfor all members of the community, includinghealth and social care staff, public andemergency service workers, retailers, businesses,schools, colleges and universities, councillors andcommunity groups, leisure and cultural facilities,care homes and housing associations.

• Reducing waiting times for assessment anddiagnosis, and improving diagnosis, prescribingand post diagnosis support.

• Providing written and verbal information aboutdementia to people who are newly diagnosed andtheir carers, about the different types of treatmentavailable to them and the kind of support on offerin Wolverhampton.

• Offering a comprehensive health and well-being assessment to carers and agreeing careplans which will help and support them in theirrole as a carer.

• Improving access to key services, including thoseprovided by voluntary and community groups.

• Enabling more people with dementia and theircarers to attend dementia cafes in the city ofWolverhampton, where they can meet otherpeople with the condition, share their experiencesand find out more about the help and supportavailable to them.

• Ensuring people with dementia and their carersplay a part in developing personalised careplans so they can maintain their independencefor as long as possible.

• Improving services for people living with dementiasuch as housing, extra care support andadaptions within the home to help maintain theirindependence for as long as possible.

• Offering people with dementia and their carershealth and well-being assessments to developcare plans which enable them to maintain ahealthy lifestyle and their independence.

• Providing carers with a range of respite andshort-break services that meet their needs, andthe needs of the person they care for.

• Increasing the number of people aged 40-74who receive NHS health checks, which includesdementia screening.

• Enabling more people with dementia and their carers to be involved in advanceddecision making.

• Supporting people to plan and prepare for end oflife care and make informed decisions abouttheir treatment.

• Improving clinical guidance for managingsymptoms for people with dementia.

• Improving access to palliative care services for people living with dementia.

6

The Joint Dementia Strategy 2015-17 included several aims and objectives which have a big impact on thelives of people with dementia. The headlines include:

There are also several pledges aimed at improving the way health, social care and other organisations worktogether to continue developing dementia services in the city of Wolverhampton. These include integratinghealth and social care teams, improving dementia awareness among practitioners and sharing best practice.


Our Progress

• Offering support and a free ‘carersassessment’ to carers of peopleaffected by dementia.

• Commissioning a new DementiaNavigator Community Service thatprovides early, and ongoing one-to-one support.

• Undertaking a targeted approach toensure people can access their fullbenefit entitlement.

• Enabling more people with dementiaand their carers to attend dementiacafes, with more cafes beingdeveloped within our communities.

• Social Care deliver MemoryMatters and Talking Points acrossthe community to raise awarenessand support people who areconcerned about their or a lovedone’s memory.

• Equipping libraries with ReadingWell Books on prescription.

• Extending social prescribing.

• Promoting independence withTelecare

• Becoming as dementia friendly aspossible, with organisations acrossthe city reviewing their services.

• Rolling out Dementia Friendly GPPractices, to raise awareness ofdementia, support diagnosis andimprove post diagnostic support.

• Strengthening the support offered incare homes, through partnershipworking on quality and providingtraining around Advanced CarePlanning and End of Life care.

• Enabling people with dementia toavoid hospital admissions byreviewing the support available inthe community through an earlyidentification project delivered bythe CCG.

• The University of Wolverhamptoncontinue to undertake researchand share their findings

• Completing timely memoryassessments for people, weachieved an average waiting timeof 7.9 weeks for the first six monthsof 2018.

• Offering a Young Onset DementiaClinic to support people diagnosedbefore the age of 65.

• Improving support for people withdementia in hospital with theenhanced Mental Health LiaisonService.

• Enhancing the experience thatpeople affected by dementia have inhospital by developing a newReminiscence Room.

• Providing excellent care, with theRoyal Wolverhampton NHS Trusts’specialist acute medical ward andoutreach service recognised as acentre of excellence.

• Supporting patients better byoffering a bespoke trainingprogramme on dementia forhospital staff.

• Delivering a cognition clinic tosupport in diagnosing people wherethere may be other causes ofcognitive impairment.

• Improving outcomes for dementiapatients by using Graphnet, whichenables GPs and Consultants toshare information.

• Developing the SWAN Programme,which will support End of Life Care.

• Developing a GSF framework tobetter equip care homes insupporting people with dementiaduring end of life.

• Sharing knowledge and improvingsupport through our Better CareFund Group.

• Extending the Red Bag ProjectWolverhampton across all carehomes and nursing homes, to helpensure patients receive safe,efficient and effective care.

• Refining our approach to dementia,by developing the first topicspecific Dementia JSNA for thecity of Wolverhampton.

7

The city of Wolverhampton is now an award-winning Dementia Friendly Community reflecting the excellentwork taking place through organisations who are members of Wolverhampton Dementia Action Alliance.Significant progress has been made in raising awareness of dementia within communities. This progress isreflected in our diagnosis rates, which are among the highest in the Country at 73.3 percent compared to67.5 percent nationwide. Wolverhampton also has 13,000 Dementia Friends in the city.

Through individual initiatives and collaborative efforts, more support is now available to people living withdementia in the city of Wolverhampton. Together, we are:

Dementia diagnosis ratein Wolverhampton

67.5% nationwide

73.3%


Key Priorities 2019 - 2024

From our engagement exercises and partnership discussions, we know a lot of good work has taken place inthe city of Wolverhampton. We are committed to continue the good work and will also continue to listen toour communities to support us in developing and improving services.

We know that our priorities need to focus on developing a whole system pathway that includes:

8

Playing our role in prevention, by promoting healthier communities and supportingthe NHS Health Checks programme - raising awareness of Cardiovascular dementiaand younger onset.

Raising awareness of available support for dementia and sharing this informationwith agencies and people affected by the condition. This includes working withpartners across health and care to improve the quality, completeness and linkage ofdata. This also includes work with Black Asian and Minority Ethnic communities, thedeaf community and adults with sight loss, to promote engagement and improveoutcomes within all communties.

Working with GP's to ensure co-ordinated support throughout a persons dementia diagnosis.

Strengthening our offer around community support, including proactive support forpeople awaiting diagnosis and improved post diagnosis support.

Enabling people with dementia to live in their communitiies for as long as possibleby ensuring a wide range of support. this includes connecting people to existing support such as existing community groups, frailty pathway, and integrated healthand social care

Extending the cultural and leisure opportunities available to ensure that people livingwith dementia can connect to their community and have opportunities to do thethings they enjoy.

Redesigning community services to facilitate a range of support that can meetpeople's needs, from young onset dementia to early stages and advanced dementia.

Strengthening our offer to carers and people affected by dementia by reviewing respite and day support.

Developing the support which helps people stay in their own homes, including careand nursing homes, thereby reducing avoidable hospital admissions and equippingpeople well as their dementia advances.

Connecting people to services and support early to avoid emergency crisissituations – this includes Advance Care Planning to enable a good death.


Joint Strategic Needs Assessmentfor Dementia

Our research and engagement with stakeholders identifiedthe following from a cohort of people diagnosed withdementia, carers and professionals:

• One in five respondents with dementia told us that theywere ‘not living well’ with the condition.

• Less than one third of respondents with dementia saidthey have used a Dementia Café in the last three years,with many not being aware of the support and othersstruggling to access the service.

• The directly standardised rate of emergency admissionsfor dementia among people aged 65 and over hassignificantly increased and is significantly higher inWolverhampton than nationwide.

• Many professionals working with dementia told us thatthey were not confident that the specific needs of people with the condition were being met or will be met in the future.

Key Recommendations:

• Raise awareness of the support available for people withdementia – especially BAME communities and connectsupport to other groups such as those people with sightloss, ‘hard of hearing’ and the deaf community.

• Connect people to the support available in thecommunity by promoting Dementia diversifying Cafes.

• Ensure health and social care professionals are aware ofthe available support and equipped to signpost and referpeople affected by dementia to the correct service in atimely way, using personalised care plans based on This is Me.

• To develop a whole system pathway to demonstrate howservices connect to support anyone diagnosed withdementia.

To see the full JSNA please visit:http://win.wolverhampton.gov.uk/dementia

91 http://www.poppi.org.uk/

Nationally and locally the number ofpeople living with dementia is rising.

In response, the City of WolverhamptonCouncil, the Royal WolverhamptonHospital Trust and WolverhamptonClinical Commissioning Groupcollaborated to produce the city’s firstJoint Strategic Needs Assessment(JSNA) for dementia.

The aim of this JSNA was to analysethe current and future ‘needs’ of peopleliving with dementia, and their carers, inthe city of Wolverhampton.

It demonstrated the relatively highprevalence of dementia in the city ofWolverhampton, with approximately 5percent of citizens aged 65 and overliving with the condition. This figure issignificantly higher than the nationaland regional rates and is expected togrow in line with national projections.The graph depicts Poppi’s projectionsfor Dementia in the city ofWolverhampton.1

2017

3,1943,346

3,720

4,176

4,703

2020 2025 2030 2035

Number of people aged 65 and overprojected to have dementia in the city of Wolverhampton (Poppi)


Our Strategic Direction: A Dementia Friendly City The various actions contained within the JointDementia Strategy supported the city ofWolverhampton’s ambitions of becoming aDementia Friendly Community. Having achievedthis status in 2018, we will continue efforts tomake the city of Wolverhampton as dementiafriendly as possible.

A dementia friendly community is one that is awareof and understands the needs of people withdementia, encourages them to seek support fromtheir local community and, most importantly, givesthem the help they need to live their lives.

It empowers people with dementia to aspire and feelconfident to take part in everyday activities, enablingthem to remain living independently and take greatercontrol over their lives.

To become a dementia friendly community, the cityof Wolverhampton needs the help and support oforganisations which people with dementia access ona regular basis, and so a local Dementia ActionAlliance has been established.

It has brought together more than 30 localorganisations, including health and social careproviders, retailers, banks, the emergency services,religious groups, education providers and more, whoare working together to ensure people live well withdementia. Each organisation has produced its ownaction plan to ensure that it responds to the needs ofpeople with dementia and their carers.

You can find out more at:win.wolverhampton.gov.uk/dementia

10

Becomingdementiafriendlymeans:

Shaping communitiesaround the views of

people with dementiaand their carers

Ensuring earlydiagnosis, personalised

and integrated careis the norm

Maintainingindependence by

delivering communitybased solutions

Appropriate transport

Challenging stigma andbuilding awareness

Befrienders helpingpeople with dementia

engage in community life

Easy to navigatephysical environments

Ensuring thatactivities include

people with dementia

Businesses andservices that respond

to customers withdementia

Empowering people withdementia and recognising

their contribution

SHOP

COMMUNITY


Guiding Principles

Our approach will be guided by the ‘I’ statements outlined in the 2020 Challenge on dementia and the NICE Quality Statements for dementia (QS30).

11

I have personal choice and control over the

decisions that affect me.

I know that there is researchgoing on which will deliver a

better life for people with dementia,and I know how I can

contribute to it.

I have support that helpsme live my life.

I have the knowledge toget what I need.

I live in an enabling andsupportive environment

where I feel valuedand understood. “I”

Statements

I am confident myend of life wishes will be respected.

I can expect a good death.

I know that services are designed around me, my needs

and my carer’s needs.

I have a sense of belongingand of being a valued part

of family, communityand civic life.


12

People worried about possible dementia in themselves or someone theyknow can discuss their concerns, and the options of seeking a diagnosis,with someone with knowledge and expertise.

People with dementia, with the involvement of their carers, have choiceand control in decisions affecting their care and support.

People with dementia participate, with the involvement of their carers, in areview of their needs and preferences when their circumstances change.

People with dementia are enabled, with the involvement of their carers, to take part in leisure activities during their day based on individualinterest and choice.

People with dementia are enabled, with the involvement of their carers, to maintain and develop relationships.

People with dementia are enabled, with the involvement of their carers, to access services that help maintain their physical and mental health and wellbeing.

People with dementia live in housing that meets their specific needs.

People with dementia have opportunities, with the involvement of their carers, to participate in and influence the design, planning, evaluation and delivery of services.

People with dementia are enabled, with the involvement of their carers, to access independent advocacy services.

People with dementia are enabled, with the involvement of their carers, to maintain and develop their involvement in and contribution to their community.

NICE QS30 Quality Statements for Dementia

1

2

3

4

5

6

7

8

9

10


Our framework

Our Aims Measures

13

The city of Wolverhampton will be ‘memory aware' andpromote risk reduction throughhealthy lifestyles.

• Number of Dementia Friends andorganisations signed up to theDementia Action Alliance

• Promoting public health and wellbeingto reduce the vascular risk factors fordementia in our city

• https://www.nhs.uk/conditions/dementia/dementia-prevention/

• Increase the number of NHS healthchecks and utilisation of dementiascreening tools

Preventing Well

People living with dementia in thecity of Wolverhampton will receivea timely diagnosis with an offer ofearly support.

• Increase the rate of timely diagnosisincluding younger onset dementia

• Reduced waiting times for a memory assessment

• Offer early support at assessment,diagnosis and beyond

• Offer information on support agencies,including benefits, carers support andDementia Café’s or groups.

Diagnosing Well

The city of Wolverhampton will be a Dementia Friendly Citythat supports people to continue to live well and connectto their community

• We will be accredited as a ‘Dementia Friendly City’

• Reduction in inappropriate prescribingof anti-psychotic medication

• More people with dementia using self-directed support

• More people with dementia and theircarers connecting to support throughtheir Navigator, who will use an asset-based approach to enable people tocontinue to live well

• People have access to communitysupport and information to preparethem for the future throughpersonalised support plans

Living Well

People living with dementia willreceive support that adapts tochanging needs with access togood quality secondary care.

The Trust will continue to deliverexcellence in dementia care withinthe Trust, when hospital admissionis unavoidable.

• Integrated support for dementia isoffered through health and social careteams and voluntary or communityorganisations – connect to existingpathways such as frailty andintegrated care

• People affected by dementia will havea named Navigator to connect them tothe available support

• Develop community teams to treatmore people in their own home leadingto;

• Reduction in admissions to acute care

• More people with dementia will havean Advanced Care Plan that includesend of life planning – including lastingpower of attorney information and support.

Supporting Well

People with dementia in the city of Wolverhampton can diewith dignity and respect

• Develop a clear understanding of theend of life pathway and the supportavailable for people affected bydementia, including families and carer

• Reduction in unnecessary hospitaladmissions within the last year of life

• Bereaved carer’s views on the qualityof end of life care received to improveoutcomes

Dying Well


Actions

Preventing Well

14

The risk of people developing dementia is minimised.

Promoting healthy lifestylesinformation with key messagesabout awareness, earlyintervention, prevention andrisk factors for developingdementia

Targeted prevention messagesin GP practices, both literature and screens.

Regular messages in carersnewsletters.

Targeted awareness by all agenciesduring Dementia Action Week andbusiness as usual.

Ensure prevention messages andhealthy lifestyles for people affectedby dementia are included as part ofpublic health events, literature and campaigns.

Ensuring existing campaigns feature dementia.

Link dementia to healthy ageing cityinitiatives and healthy lifestyles.

Collect baseline of NHS healthchecks and measure the increase ofthe number of people taking them.

Ensure Dementia Friends Sessionscontinue to be delivered in all areasof the community.

NHS Well Pathway Aim

Outcome Action

Raising awareness to seekassessment early if there arememory concerns

Leaflets available in health servicescovering hospital, primary care andcommunity settings (e.g.pharmacies)

Promote Memory Matters andTalking Points as ways to discussearly concerns.

Continued service user, carer andprovider engagement.

Enable key staff such ascommunity nurses, Dom careand care home staff are aware ofprevention and risk reductionand where to signpost

Increase the number of DementiaFriendly GP Practices.

Increase the number of NHS Healthchecks and the utilisation ofdementia screening tools.

Promote dementia friendly trainingand sessions as part of inductions.

Increase early diagnosis andaccess to targeted groups –including all protectedcharacteristics

All agencies to promote awarenessand support information to BMEcommunities, people withdisabilities, deaf communities andthose with co-morbidities. This includes people under 65.


15

Diagnosing Well

Timely, accurate diagnosis, a care plan and a review within the first year for all.

Continue to increase therate of timely diagnosis

Work with NHS England to delivertargets in place.

Memory Matters Service continues toraise awareness and strengthenreferral to GP.

NICE Statement/ Dementia Declaration

Outcome Action

Reduced waiting times for amemory assessment

Strengthen and formalise theassessment process where peoplereceive a diagnosis at RWT byensuring the screening and cognitionpathway is utilised.

Ensure GP’s discuss diagnosis withpatients when diagnosis is receivedand signpost to Dementia NavigatorCommunity Service for postdiagnostic support.

Continue to strengthen diagnosis inacute settings and offer dementiasupport at RWT through staffinduction and utilising dementiaoutreach team.

Ensure BCPFT maintain assessmentwaiting times below the 12-weekthreshold.

Explore a high-quality memoryassessment through the achievementof MSNAP accreditation.

Explore the diagnostic role incommunity pathways such aspharmacies and community nursesand strengthen communication whena diagnosis is made, to ensure postdiagnostic support is available earlier on.

Improve diagnosis rates in carehomes through early identification.Staff to receive appropriate training.

People are offered earlypost diagnostic supportat assessment, diagnosisand beyond

Care Navigators at GP surgeries refer to Dementia NavigatorsCommunity Support Service andCarer Support Team.

GP’s are given messages on earlysupport, dementia friendly initiativesand continue to deliver on QOF targets.

Explore Dementia Navigators joiningBCPFT at the end of assessmentprocess to strengthen postdiagnostic support.

Community nurse teams know howto refer to Dementia Navigators.

Share information on supportagencies, including benefits, carerssupport and Dementia Café’s onwebsites, leaflets, GP.


16

Living Well

People with dementia can live normally in safe and accepting communities.

More people with dementia and theircarers connecting to support through theirNavigator, who will use an asset-basedapproach to enable people to continue tolive well. Ensure high quality, appropriatepost-diagnostic support is available to all,including younger people, those withcomorbidities and those from BME groups

Ensure all agencies are referringdirectly to the Dementia NavigatorSupport Service delivered by theAlzheimer’s Society.

Make links with BME groups,community and faith groups.

Advertise all post diagnostic supportavailable to the public andprofessionals.

Explore Dementia Navigatorsmeeting patients at Assessment.


Outcome Action

More people with dementiaengaged with agreeing advancedcare plans and using self-directed support

Dementia Navigators will ensure aplan is in place that promotesindependence and supports inplanning for changes in the future.

An asset-based approach will betaken to support people in what theycan continue to do, like to do andenjoy doing to enable people to livefulfilling lives. This includes, healthylifestyles, community activities,dementia cafes and benefit checks.

Information on where to go whenthings change will be readilyavailable to avoid patients and carersentering crisis.

All agencies will encourage peopleaffected by dementia to plan for thefuture with early conversations andrefer where appropriate, tocompassionate communities anddying well.

Continue the work of theDementia Action Alliance andremain accredited as a DementiaFriendly Community

Deliver community events.

Increase members.

Increase in number of dementia friends.

Expand activity to schools andtransport.

Explore cultural, leisure and socialopportunities are available andpromoted.

Carers and family support Continue the assessment andsupport delivered by the CarerSupport Team.

Explore the development of theCRISP programme for carers.

Ensure carers needs are assessedand support is in place to maintaintheir own wellbeing.

Enable carers to access support andpromote community supportavailable to them.

Promote independence Information on what is available isaccessible in all community andstatutory agencies.

Explore the possibility ofcommissioning Admiral nurses.

Navigators will make referrals toenable people to continue theirindependence by referring toassistive technology, welfare support and where to seek adviceand guidance.


17

Supporting Well

Access to safe, high quality health and social care for people with dementia and carers.

People affected by dementia will have anamed Navigator to connect them to theavailable support

All agencies to refer. All services are equipped to signpost people to support,particularly for people who arereceiving a late diagnosis.


Outcome Action

More people with dementia willhave an Advanced Care Plan thatincludes end of life planning.

Early conversations by all care co-ordinators to ensure the completionof an Advanced Care Plan- servicesare quipped to refer to teams thatcan complete Plans.

Care plans should be personalisedand specific on patient's wishes anddeter hospitalisation which wouldcause further deterioration.

All patients will have a Care Plan, and this will be based on ‘This is me’- this should include information onmental capacity and lasting powerof attorneys.

Integrated support for dementiais offered through health andsocial care teams and voluntaryor community organisations

Supporting Well strategy groupcontinues to meet and ensuresshared information to improveservices by problem solving andsharing information. This mayinclude, shared protocols andtraining between services. Co-ordination of services to beimproved and full offer of support tobe mapped and implemented.

Agencies make connections toexisting services, such as the Frailtypathway and Telecare.

Explore Frailty Co-ordinators in GPclinics who will connect to health andsocial care services.

Report the impact of EPAC oncerolled out – improve the expectationsof GP’s as care coordinators onceEPAC is in place and LES in place.

Developing community teams totreat more people in their ownhome leading to below;

Supporting Well strategy groupcontinues to meet and ensuresshared information to improveservices by problem solving andensuring actions are undertaken.

Explore GP groups who have aninterest in dementia and serviceimprovement.

Reduction in admissions to acute care Review respite and day support forpeople affected by dementia anddevelop a new model in line withmodernised day services andincorporating new health communityteam input.

Map independent communityservices such as Age concern sittingservice, carer support, communitysupport and extra care schemes.


18

Supporting Well

Access to safe, high quality health and social care for people with dementia and carers.

Improving the quality of care in thecommunity to reduce unplannedadmissions, delayed discharges andplacement breakdowns

Rapid Intervention Team alreadytreating people in care homes and athome. This offer to be formalised tosupport hospital avoidance.

Develop a bespoke community teamthat offers clinical support to carehomes and to people in their home.Particularly to improve outcomes forpatients with dementia wherehospital admission often providesfurther challenges and confusion.Explore mental health teams hometreatment team and crisis resolution model.

Explore a targeted training andsupport package to those homeswith high admissions to hospital.

Explore Dementia Outreach Teamand expanded offer in hospital to home.

Develop D2A and Reablementpathway to ensure staff andprofessionals are able to supportpeople with their primary goals with adementia diagnosis.

Work with the Integrated CareAlliance to ensure outcomes aremonitored and recorded.

Work with care home, domiciliary andcare home staff to equip them insupporting people with dementia.

Quality assurance teams to sharebest practice within care homes toraise improvements in dementiafriendly environments and activities.

Explore national models ofcommunity support and targetedsupport for people with advanceddementia.

Explore Admiral nursing programmeto deliver training to healthprofessionals.

Ensure all agencies have and refer toThis is Me /About Me document –continued use in Red Bag.


Outcome Action

Excellence in Dementia CareProgramme

The Trust will continue to developand deliver the Excellence inDementia Care programme throughthe development and delivery ofRWT’s Strategy and campaigns.

Dying Well

People with dementia die with dignity and in the place of their choosing

Develop a clear understanding of the endof life pathway and the support availablefor people affected by dementia, includingfamilies and carers

Share the pathway within the End ofLife strategy - ensure criterion are asflexible as possible to provide aperson-centred approach.

Ensure information is given to peopleabout mental capacity and lastingpower of attorneys.

Ensure agreed documentation is inplace for teams who can completeAdvanced Care Plans, advanceddirectives and refusal for treatmentand that they are aware ofresponsibilities.

Continue the work between qualityteams and care homes to equip staffwith difficult conversations andensure correct documentation is inplace.

Build on the work between ComptonCare and CCG to ensure staff areconfident to deliver this pathway andpromote available training on end oflife care conversations.


Outcome Action

Reduction in unnecessaryhospital admissions within thelast year of life

Explore the expansion of low-levelpalliative care and support.

Promote rapid discharge to homepathway as this is currentlyunderutilised.

Bereaved carer’s views on thequality of end of life carereceived

Promote Bereavement Hubs thatprovide advice and opportunities toconnect with people who are in thesame position as you.

Continue to deliver Dying Mattersawareness weeks and promotingconversations.

Ensure support plans and plans inplace are used to respect patient’s wishes.

Ensure everyone has access toinformation to enable a good death.

Test the pathway Undertake a walkthrough of alldementia interfaces and services.This will enable further understandingto develop areas and share good practice.


19


Dementia Action Alliance

The City of Wolverhampton’s Dementia Action Alliance is part of a national movement which aims toencourage and support local communities and organisations to bring about a society-wide response,including practical actions which enable people to live well with Dementia. The Alliance is co-ordinatedthrough City of Wolverhampton Commissioning Team and chaired independently. Some examples of ourmembers actions include, ensuring all staff become Dementia Friends, holding social spaces for peopleliving with dementia and their carers, holding awareness days in their organisation and during DementiaAction Week, making their space more dementia friendly.

Members of Wolverhampton Dementia Action Alliance include but not limited to:

We hope our membership continues to grow -to become a member please contact the People Commissioning Team [email protected]

20

Age UK

Alzheimer’s Society

Asda

Accord

Beacon Centre

Black Country Partnership NHSFoundation Trust

BME United

Citizen’s Advice Bureau

City of Wolverhampton Council

Compton Care

Dementia Friendly GP Surgeries

Dementia UK

Diocese of Lichfield

FBC Manby Bowdler Solicitors

Fiddle Finger Quilts

Grand Theatre

Healthwatch

HSBC Bank

Home Instead

Interfaith Wolverhampton

Lloyds Bank

Memory Matters

Mid-Counties Co-op/Alz Cafe

Newhampton Arts Centre

Ring and Ride

The Royal Wolverhampton NHS Trust

Trading Standards

University of Wolverhampton

West Midlands Fire Service

West Midlands Police

West Midlands Ambulance Service

Wolverhampton ClinicalCommissioning Group

Wolverhampton Homes


Dementia Friends

As well as providing dementia awareness trainingto people from all walks of life, the JointDementia Strategy also seeks to encourage morepeople to become Dementia Friends.

Nationally, more than one million people have signedup to become Dementia Friends through theAlzheimer’s Society, and in doing so have developeda greater understanding of dementia, and what canbe done to help people who are living with theconditions. Becoming a Dementia Friend does notmean befriending someone with Dementia.

In Wolverhampton we have over 13,000 registeredDementia Friends! We hope this number continues togrow. Anyone can become a Dementia Friend andthere are many ways in which you can become aDementia Friend, to find out more please visitwww.dementiafriends.org.uk for more details.

21


Appendix: key standards

• Prevention (NICE Guideline)

• Risk reduction (OECD Dementia Pathway)

• Health information (NICE Pathway)

• Supporting research (OECDDementia Pathway)

• Preventing people dyingprematurely (NHS OutcomesFramework)

• Diagnosis (NICE Guideline andOECD Dementia Pathway)

• Memory assessment (NICE Guideline and NICE Quality Standard 2010)

• Concerns discussed (NICE Quality Standard 2013)

• Investigation (NICE Pathway)

• Provide information (NICE Pathway)

• Integrated and advanced careplanning (NICE Guideline, NICEQuality Standard 2010, NICEQuality Standard 2013 and OECDDementia Pathway)

• Healthcare public health andpreventing premature mortality(Public Health OutcomesFramework)

• Integrated services (NICE Guideline, NICE QualityStandard 2013 and OECDDementia Pathway)

• Supporting carers (NICE QualityStandard 2010, NICE Pathway andOECD Dementia Pathway)

• Carers respite (NICE Quality Standard 2010)

• Coordinated care (NICE Guidelineand OECD Dementia Pathway)

• Promote independence (NICEGuideline and NICE Pathway)

• Relationships (NICE QualityStandard 2013)

• Leisure (NICE Quality Standard 2013)

• Safe communities (NICE QualityStandard 2013 and OECDDementia Pathway)

• Enhancing quality of life for peoplewith long-term conditions (NHSOutcomes Framework)

• Choice (NICE Quality Standard2010, NICE Quality Standard 2013and NICE Pathway)

• Behavioural and psychologicalsymptoms of dementia (NICEQuality Standard 2010)

• Liaison (NICE Quality Standard 2010)

• Advocates (NICE Quality Standard 2013)

• Housing (NICE Quality Standard 2013)

• Hospital treatments (NICE Pathway)

• Technology (OECD Dementia Pathway)

• Health and social services (OECD Dementia Pathway)

• Hard to reach groups (NICE QualityStandard 2013 and OECDDementia Pathway)

• Ensuring people have a positiveexperience of care (NHS Outcomes Framework)

• Treating and caring for people in asafe environment and protectingthem from avoidable harm (NHSOutcomes Framework)

• Palliative care and pain (NICEGuideline and NICE QualityStandard 2010)

• End of life (NICE Pathway)

• Preferred place of death (OECD Dementia Pathway)

• Prime Ministers Challenge 2020

22 2 https://www.gov.uk/government/publications/challenge-on-dementia-2020-implementation-plan

Our Joint Dementia Strategy and Joint Strategic Needs Assessment will underpin the work we do to improveoutcomes for people living with dementia and their carers in the city of Wolverhampton.

We are also aligning our approach with the national ‘2020 Challenge on Dementia Implementation Plan’(2016).2 This plan sets out a ‘Well Pathway’ for people’s journey with dementia and will continue to holdpertinence in the future. The city of Wolverhampton has aligned its measures and actions for support fordementia with this framework, as set out within this document.

Other key standards include:


Glossary

Glossary of key health and social care terminology that has been used in this document:

BCPFT Black Country Partnership Foundation Trust

BME Black and Minority Ethnic

CCG Clinical Commissioning Group

CRISP Carer Information Support Programme

D2A Discharge to Assess

EPACC Electronic Palliative Care Co-ordination

GP General Practitioner

GSF Gold Standard Framework

JSNA Joint Strategic Needs Assessment

LES Local Enhanced Service

MSNAP Memory Services National Accreditation Programme

NHS National Health Service

NICE The National Institute for Health and Care Excellence

OECD Organisation for Economic Co-operation and Development

POPPI Projecting Older People Population Information System

QOF Quality and Outcome Framework

RWT Royal Wolverhampton Trust

SWAN End of Life Programme

THIS IS ME A support tool to enable person-centred care

23

The Joint Dementia Strategy 2019-24 is supported bymembers of Wolverhampton Dementia Action Alliance.

WCC

123

5 0

7.19

Joint Dementia Strategy 2019–24 · 2019. 9. 3. · • Improving access to palliative care...

Documents

Transcript of Joint Dementia Strategy 2019–24 · 2019. 9. 3. · • Improving access to palliative care...